| NPI | 1740940006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA100965) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA 1175447) |
| Enumeration Date | 2021-12-28 |
| Last Update Date | 2024-11-06 |